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As long as surgery remains the primary therapy for the curative treatment of lung cancer, patients will continue to require pneumonectomy to treat lung cancer, as well as other occasional problems.1 However, no other operation done by surgeons carries as high a risk. Operative mortality from pneumonectomy has been reported to be between 5% and 20%.2–8 These numbers are probably somewhat conservative because most of the published articles report only 30-day mortality—the real operative mortality is likely higher. For this reason, appropriate selection, operative technique, and postoperative management of patients who potentially may undergo pneumonectomy is crucial. The term potentially applies because patients scheduled for pneumonectomy ultimately may undergo pneumonectomy, sleeve resection, or exploration without resection depending on the findings at surgery.

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Surprisingly, low preoperative lung function has not been demonstrated consistently to increase the perioperative risk of pneumonectomy, although some authors have found preoperative lung function to be an important factor.9–11 This may be the result of diligent efforts to identify and eliminate patients with poor pulmonary function from the surgical pool. Other factors have been shown to increase the perioperative risk, includiung increased age,7,8,10,12,13 right-sided procedures,8,11–14 preoperative chemo/radiation,11,15 large intraoperative fluid volumes,11,15,16 perioperative cardiac dysrhythmias,12 and immediate preoperative smoking history.11,17

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This chapter concerns the preoperative evaluation and management of pneumonectomy patients, the decision to perform pneumonectomy rather than sleeve resection, the technical aspects of the operation, and the postoperative management, all with the goal of decreasing perioperative mortality.

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Staging

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Patients who undergo pneumonectomy first should undergo preoperative staging (Table 64-1). At this time, a complete history and a physical examination that focuses on the identification of lymph nodes and liver masses, followed by a chest CT scan and a PET scan, are appropriate. This evaluation will rule out distant metastases other than brain metastases. Patients without symptoms of headache are unlikely to have brain metastases, and brain CT scans or MRIs are not obligatory. However, the risk of the procedure supports appropriate evaluation to rule out brain metastases (see Chap. 78).

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Table 64-1. Preoperative and Preresection Staging for Potential Pneumonectomy Patients
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Patients who are candidates for pneumonectomy typically have large or hilar masses and a high likelihood of having mediastinal metastases. Although PET scans are quite sensitive for detecting mediastinal metastases, they remain less accurate than mediastinoscopy18 (see Chap. 61). For this reason, preoperative mediastinoscopy is indicated for patients who may undergo pneumonectomy, even if they have a PET-negative mediastinum. The PET scan remains a useful study for ruling ...

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